Lower Back Survey

Please let us know about the current status of your effected area

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Name *

First

Last

Email *

During the past week, for how many days have you experienced pain in the effected area? *

On a scale of 0 (no pain) to 10 (severe pain), when you experience the pain, how bad has it been? *

To what extent does avoiding activities due to a fear of aggravating the effected area impact your quality of life? *

During what type of activities do you experience pain from the effected area? (tick all that apply) *

Inactive (sitting, standing or laying down) Walking Getting in and out of a seated position Picking up and moving objects Moderate activity or exercise (jogging, hiking, cycling, swimming) Strenuous activity or exercise (BJJ, lifting weights, playing other sports)

On average, over the past month, how many days per week have you missed Jiu Jitsu training because of the pain? *

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Please let us know about the current status of your effected area

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